We read the letter of Bellelli et al with interest. One of the great therapeutic dilemmas is that of warfarin for stroke prophylaxis in the elderly. Although the elderly are certainly at higher risk for the adverse effects of warfarin, they also derive the most benefit because of their higher risk for stroke. With our aging population, and the higher attributable risk of atrial fibrillation and stroke in the elderly, this is highly relevant to practice. As Bellelli et al point out, perhaps the best compromise is careful and systematic patient assessment. To this we would also suggest close monitoring through a specialized anticoagulation monitoring service, which has been shown to reduce adverse effects and improve patient outcomes.1